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CDPHP DELTA DENTAL PLAN Eligibility Primary enrollee, spouse (includes domestic partner) and eligible dependent children to the end of the month that dependent turns 26 Deductibles: $50 per person / $150 per family each plan year Yes $2,000 per person each plan year No Major Restorative, Prosthodontics & Orthodontics - 6 Months Deductibles waived for Diagnostic & Preventive (D & P)? Maximums: (Orthodontic maximums below) D & P counts toward maximum? Waiting Period(s) Benefits and Covered Services* Delta Dental PPO dentists** Non-PPO dentists **(Delta Dental Premier® & Non-Delta Dental Dentists) Diagnostic & Preventive Services: Exams, 100 % 100 % 80 % 80 % 80 % 80 % 80 % 80 % 80 % 80 % 50 % 50 % Prosthodontics: Bridges and dentures, implants, TMJ 50 % Orthodontic Benefits: dependent children to the 50 % 50 % Orthodontic Maximums $ 1,000 Lifetime cleanings, x-rays, sealants Basic Restorative: fillings, posterior composites Endodontics: (root canals) Periodontics: (gum treatment) Oral Surgery Major Restorative: Crowns, inlays, onlays and cast restorations end of the month that dependent turns 19 $ 1,000 Lifetime 50 % Monthly Premiums: Single: $43.44 | Employee/child(ren): $85.48 | Employee/spouse: $88.02 | Family: $135.81 Enrollment Requirements: IF company is a CDPHP medical subscriber none. IF not a CDPHP medical subscriber 50% or 5 whichever is less. * Limitations or waiting periods may apply for some benefits; some services may be excluded from your plan. Reimbursement is based on Delta Dental maximum contract allowances and not necessarily each dentist’s submitted fees. ** Reimbursement is based on PPO contracted fees for PPO dentists, Premier contracted fees for Premier dentists and Premier contracted fees for nonDelta Dental dentists.